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The International Journal on Orbital Disorders, Oculoplastic and
Lacrimal Surgery
ISSN: 0167-6830 (Print) 1744-5108 (Online) Journal homepage:
A rare case of orbital granulomatous inflammation
from explosive hydraulic oil masquerading as
orbital cellulitis
Marvi Cheema, Kelsey Roelofs, Imran Jivraj, Robert West, Steve Rasmussen
& Audrey Chan
To cite this article: Marvi Cheema, Kelsey Roelofs, Imran Jivraj, Robert West, Steve Rasmussen
& Audrey Chan (2017): A rare case of orbital granulomatous inflammation from explosive hydraulic
oil masquerading as orbital cellulitis, Orbit, DOI: 10.1080/01676830.2017.1383457
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Published online: 20 Oct 2017.
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Download by: [University of Florida]
Date: 27 October 2017, At: 09:58
A rare case of orbital granulomatous inflammation from explosive hydraulic oil
masquerading as orbital cellulitis
Marvi Cheemaa, Kelsey Roelofsa, Imran Jivraja, Robert Westb, Steve Rasmussenc,d, and Audrey Chana
Department of Ophthalmology, University of Alberta, Edmonton, Canada; bDepartment of Laboratory Medicine and Pathology, University of
Alberta, Edmonton, Canada; cDepartment of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, Canada;
Department of Laboratory Medicine and Pathology, University of British Columbia, Vancouver, Canada
Downloaded by [University of Florida] at 09:58 27 October 2017
The differential diagnosis for acute orbital inflammation is broad. We report a case of granulomatous orbital inflammation due to high-pressure oil injury to the orbit presenting as an atypical
orbital cellulitis. Here we review the presentation and treatment of orbital inflammation from oil.
Received 1 December 2016
Accepted 19 September 2017
Grease; lipogranulomatous
inflammation; orbital
cellulitis; orbital
A 65-year old man presented to the ophthalmology
clinic with a 6-day history of worsening left periorbital swelling and diplopia. On examination, he was
afebrile and comfortable. Visual acuities were 20/20
OD and 20/60 OS and optic nerve function was
intact bilaterally. Extensive left sided periorbital
edema was evident. Ductions were severely limited.
Slit lamp examination revealed chemosis and conjunctival injection OS. Exophthalmometry revealed
8 mm of proptosis. Intraocular examination was
A contrast-enhanced CT scan of the orbits showed
extensive preseptal and intraconal inflammation with a
prominent collection adjacent to the left optic nerve,
and numerous hypodense loculated spaces within the
orbit. (Figure 1).
The patient was diagnosed with atypical orbital cellulitis and treated with broad spectrum intravenous
antibiotics. Given clinical worsening over the next
48 hours, an orbital biopsy was arranged.
Intraoperatively, firm yellow–white material was
found throughout the orbicularis and orbital fat; the
abnormal tissue was debrided and specimens were submitted for culture and pathology.
Upon histopathologic examination, a florid lipogranulomatous response was noted. Granulomas, composed primarily of histiocytes and a few
multinucleated giant cells, were identified surrounding
multiple optically clear spaces. (Figure 2).
The patient had earlier denied any history of trauma,
however, upon further questioning, recalled being
struck by a pressurized jet of hydraulic oil while repairing his tractor 3 weeks prior to presentation. He had
been asymptomatic in the interim.
After orbital biopsy and debridement, he received 1
g of IV solumedrol for 3 days followed by a 2-week oral
prednisone taper. The patient responded rapidly to
treatment with preserved visual function and substantially improved periorbital swelling, motility, and
The differential diagnosis for acute orbital inflammation is broad. A complete history should encompass the
onset and duration of pain and orbital symptoms, associated trauma or foreign body exposure, the presence of
fever and constitutional symptoms, previously diagnosed sinusitis, thyroid disease, vasculitic entities,
immunosuppressive conditions or medications, malignancy, and a thorough review of symptoms.1
Our patient denied antecedent skin trauma, sinusitis,
or significant pain. He was afebrile and laboratory
studies showed an absence of leukocytosis. There was
no skin wound or obvious entry site for a foreign body.
CT identified preseptal and intraconal inflammation
and atypical hypodense loculated spaces which raised
CONTACT Audrey Chan
Department of Ophthalmology and Visual Sciences, University of Alberta, Royal Alexandra
Hospital, 2319 10240 Kingsway Avenue NW, Edmonton, AB, T5H 3V9, Edmonton, Canada.
Color versions of one or more of the figures in the article can be found online at
© 2017 Taylor & Francis
Downloaded by [University of Florida] at 09:58 27 October 2017
Figure 1. Contrast enhanced CT images of the orbits with axial, coronal, and sagittal views demonstrating (a) Significant axial
proptosis and extensive preseptal and intraconal inflammation with a localized collection adjacent to the optic nerve; (b) and (c)
Numerous hypodense loculated spaces within the orbit.
Figure 2. (a) Florid granulomatous foreign body inflammatory reaction associated with abundant optically clear spaces (50X); (b) and
(c) Closer look at granulomas and clear spaces (100X); and (d) Large oil droplet surrounded by granulomatous inflammation
including numerous histiocytes and a few multinucleated giant cells.
concern for gas-forming anaerobic organisms. Orbital
biopsy revealed evidence of lipogranulomatous inflammation with vacuolated spaces compatible with oil,
rather than gas. Our patient’s later recollection of antecedent injury with pressurized hydraulic oil confirmed
the diagnosis. In our case the oil likely entered the orbit
via the conjunctival fornix, and inflammation at the site
obscured the evidence of minor trauma.
To our knowledge, this is the seventh reported case
of grease gun injury resulting in orbital lipogranulomatous inflammation.2–6 Patients have presented to care
immediately following injury4 or, in the case of an
eyelid lipogranuloma following hydraulic oil injury,
up to 1 year later.7 Grease gun trauma may cause
penetrating foreign body injuries without a significant
or noticeable entry wound, especially when the initial
wound has healed over in later presentations.4 Similar
presentations have been reported with silicone oil after
vitreoretinal surgery, following paraffin ointment use in
lacrimal and endoscopic sinus surgery and following
cosmetic hyaluronic acid, poly-L-lactic acid, and polyalkylimide fillers.8–14 Injections at sites distant from the
orbit, such as the nasolabial folds, may lead to periorbital inflammation after migration.14 Presenting symptoms include pain, orbital swelling, decreased vision
and diplopia, and visual acuity at presentation ranges
from 20/40 to light perception.2–6 On orbital imaging,
grease appears as cysts or hypodense masses within
subcutaneous tissues or disruption of fat. 3,5,6 During
surgical exploration, extrusion of grease from orbital
tissues has been described.2–6 The histopathological
diagnosis must be distinguished from liposarcoma
which may share pathological features.15
Management of granulomatous orbital inflammation
from exogenous oil varies from immediate surgical
exploration and thorough removal of oil8 to close
observation of asymptomatic patients.5 Our case
demonstrates that atypical features should prompt an
orbital biopsy and surgical debridement. If not adequately debrided, it is possible that residual foreign
material could elicit a similar inflammatory episode in
the future once corticosteroids have been tapered.
Downloaded by [University of Florida] at 09:58 27 October 2017
Our case emphasizes the importance of attention to
atypical features in determining the etiology of an orbital inflammatory process. In the presence of such features, or without satisfactory response to appropriate
empiric antibiotics, there should be a low threshold for
obtaining orbital biopsy for microbiologic and pathologic studies. We advocate that surgical debridement is
a key step in the management of cases presenting
similarly to ours, and suggest that adjuvant corticosteroid therapy be considered.
Disclosure statement
The authors have no proprietary or financial interests to
This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit
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